Toward the end of 1999, a man with paranoid schizophrenia named Michael Abram slipped into the British mansion of former Beatle George Harrison and stabbed him with a knife. Apparently voices in his head had told him that the Beatles were witches.

Abram had been in a hospital psychiatric ward shortly before he stabbed Harrison. Abram’s mother, Lynda Abram of Stockbridge Village, Merseyside, England, wondered why he hadn’t been kept confined so that the attack on Harrison would never have occurred, according to the London Telegraph. The incident raised this question in the minds of some Americans: How are individuals with paranoid schizophrenia who are potentially dangerous to other people handled under the British mental health system?

Interviews with some British psychiatrists suggest that the answers are complex.

For instance, under the revision of the British Mental Health Act in 1983 it is only possible to detain patients against their will and admit them as involuntary patients to a psychiatric hospital if a positive diagnosis of a psychiatric disorder can be agreed upon by a group of professionals, which will usually include a senior psychiatrist, a general practitioner, and a social worker, and if it can be demonstrated that the psychiatric disorder puts the sufferer or others in the community at risk. Fulfilling such requirements is not always easy, said Gordon Turnbull, M.D., a consultant psychiatrist and codirector of the Traumatic Unit at Ticehurst House, a psychiatric hospital near Tun Bridge Wells, East Suffix, England.

"You can see immediately," he said, "that it might be possible for a sufferer from a condition such as paranoid schizophrenia, typically with well-preserved personality including control over expression, to maintain a secret agenda in the face of such a group."

There has also been a strong movement in Britain toward treatment of psychiatric patients in the community rather than in institutions.

"If community services can be provided, there are many people in hospital who can safely be cared for in the community," said Stuart Turner, M.D., a psychiatrist in charge of the Traumatic Stress Institute in London. The problem with this approach, though, Turnball said, is that it is expensive and has not been properly funded by the British health system. Thus it is conceivable that, in Britain, paranoid schizophrenic patients might pose a danger to others simply because they are not getting the treatment in the community that they need. In fact, Ray and Lynda Abram—Michael Abram’s parents—claim that their son had been abandoned by the care services from which he had sought help, according to the London Telegraph.

More widespread problems with the health care system in Britain may have likewise contributed to Abram’s liberty to attack Harrison and, in fact, may be providing other people with paranoid schizophrenia with similar opportunities for violence. According to Michael Launer, M.D., a psychiatrist and clinical director of the Lamont Clinic in Burnley, Lancashire, England, there are only a handful of mental hospitals, a shortage of psychiatrists and nurses, and a lack of money for medications—rendering British services for schizophrenia in general woefully inadequate. In fact, Launer goes so far as to contend that the whole British medical system is falling to pieces—not necessarily because it is socialized, but because so little money is spent on it.

"The percentage of the gross domestic product for health in the United Kingdom is among the lowest in Europe," he explained. "I think there are only one or two other countries that spend less than we do. Basically we are not spending enough on health in the U.K."

Launer is aware that American psychiatrists tend to be unhappy with managed care because he travels to the United States quite often for conferences. But "things over here, I would say, are worse," he lamented.

In fact, a strong cultural bias might have also helped set the stage for Abram’s dismissal by the British mental health system and perhaps also leads to a cavalier disregard of other persons with paranoid schizophrenia who are potentially dangerous. And that is the British tendency to deny problems whatever their nature, the so-called British "stiff upper lip." This, at least, is Turnbull’s opinion.

"I think that this attitude has deep roots in our society," he told Psychiatric News. "I think that some leading lights in our psychiatric world in the United Kingdom still believe that ‘parachutes are for sissies.’"

But if you believe that cases such as Abram’s would be handled more judiciously in the United States than in Britain, don’t be so sure, some American psychiatrists who specialize in the psychiatric aspects of violence make clear. To wit: Individuals with paranoid schizophrenia can be dangerous to other people if they go untreated or are under the spell of command or hallucinations, or if their suspiciousness is geared toward a single person or class of people.

If they are manifestly psychotic, they generally come to the attention of the mental health system, explained Paul J. Fink, M.D., chair of the APA Task Force on Psychiatric Aspects of Violence and senior consultant to Charter Behavioral Health Systems in Bala Cynwyd, Pa. These individuals are taken to an emergency room, but state rules must be followed regarding involuntary admission to an inpatient facility. One consistent criterion for involuntary admission, however, is that patients have to be dangerous either to themselves or to others, but assessing the danger of such patients isn’t always easy. Psychiatrists have to take into account not just threats that a patient has made but whether he or she has a history of acting out, how the patient has responded to treatment, the kinds of stresses the patient is currently under, and other factors. Or as Sandra Lynn Bloom, M.D., a member of the APA Task Force on Psychiatric Aspects of Violence and president of the Alliance for Creative Development in Quakertown, Pa., puts it: "Lots of people make threats and don’t act on them, and lots of people who don’t make threats act violently. So the person has to present a pretty clear and present danger to themselves or other people."

It can be likewise difficult for psychiatrists to determine when a person with paranoid schizophrenia should be discharged from a facility. Sometimes, Fink said, patients learn to play the game and act better when they really aren’t. This point was also made by Britain’s Turnbull.

Still another obstacle to keeping these patients from posing a threat to others is that in the United States the hospital stay for them is typically very short, said Fink, who is also a former APA president. Basically, it is to stabilize them rather than to manage their illness or cure them. "So we depend a lot on people treating them after they have been discharged, which doesn’t always happen," said Fink.

When individuals with paranoid schizophrenia also abuse drugs, which was the case for Michael Abram, that makes it even tougher for mental health workers to treat them successfully and thus protect the public from them, pointed out Carl C. Bell, M.D., of the Community Mental Health Council in Chicago and vice chair of the APA Task Force on Psychiatric Aspects of Violence.

"The reality here," Bell explained, "is that 30 percent of the people who use drugs are psychiatrically ill, and 70 percent of the psychiatrically ill people use drugs. So you would think that there would be a seamless, coherent treatment system. But what actually happens is that some people specialize in mental health, and some people specialize in drugs, and never the twain shall meet, which is, of course, a problem. We are doing a little bit better in this country toward addressing that dually diagnosed. . .population. But you have to address both pieces of the puzzle, or the patient can’t be helped."

Thus, as Michael Abram’s near-fatal attack on George Harrison reveals, the care of potentially dangerous persons with paranoid schizophrenia in Britain leaves something to be desired. Yet the same can also be said about the care of such individuals in the United States. And even if all the best doctors, nurses, health care facilities, medications, and coordinated care were available for the treatment of such patients, a basic challenge would remain—identifying those who are a threat to others and confining them at the moments when they are ready to take action against others. Or as Bloom put it: "We don’t read minds."

So while there is no doubt that some patients with paranoid schizophrenia will continue to present a threat to other people, there is a much more positive aspect to the subject of paranoid schizophrenia and violence as well. It was pointed out in the November 1999 Journal of Practicing Psychiatry and Behavioral Health by Karen A. Nolan, Ph.D., of the Nathan Kline Institute in Orangeburg, N.Y., and her colleagues: "[M]ost patients with schizophrenia are not violent, and most of the violence in the community is not attributable to schizophrenia. . . ."